Post on 24-Apr-2023
It’s not about the hoist: Anarrative literature review ofmanual handling in healthcare
Kate KayPhD candidate, School of Nursing, Midwifery and Paramedicine, Australian Catholic University,
Australia
Nel GlassResearch Professor in Nursing, School of Nursing, Midwifery and Paramedicine, Australian Catholic
University, Australia
Alicia EvansSenior Lecturer, School of Nursing, Midwifery and Paramedicine, Australian Catholic University,
Australia
Abstract
The manual handling of people and objects is integral to the provision of nursing care to patients
globally. Despite over 30 years of research intended to guide improvements for nurses’ safety,
substantial rates of manual handling injuries persist internationally within the nursing profession.
This paper reviews the contemporary international literature regarding manual handling
interventions noting the unique context for injury prevention strategies within healthcare. The
review includes the recognition of underlying assumptions inherent in the conceptualisation of
manual handling and its management, and the preponderance of the post-positivist paradigm in
this field.
The complexity of manual handling in healthcare has resulted in a theoretical shift from single
factor interventions based on technique training towards an emerging multidimensional approach.
However the key elements for sustainable solutions to reduce nurses’ manual handling injuries
have not yet been identified and consensus is lacking regarding the implementation and
appropriate evaluation of injury prevention programmes. Furthermore, whilst the literature is
replete with data derived from surveys or insurance industry records of compensation claims,
there is a dearth of literature exploring nurses’ manual handling experiences. The in-depth
investigation of nurses’ perspectives on manual handling may uncover new knowledge critical
to improvement of the manual handling issues.
Corresponding author:
Nel Glass, Research Professor in Nursing, School of Nursing, Midwifery and Paramedicine, Australian Catholic University,
Locked Bag 4115, Fitzroy, Melbourne 3065, Australia.
Email: Nel.Glass@acu.edu.au
Journal of Research in Nursing
2014, Vol. 19(3) 226–245
! The Author(s) 2012
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1744987112455423
jrn.sagepub.com
Keywords
injury prevention, interventions, manual handling, manual handling injuries, moving and handling,
nurses
Introduction
Despite more than 30 years of international research, substantial rates of manual handlinginjuries persist within the nursing profession (Nelson et al., 2006). The injuries sustained bynurses may have long lasting physical, psychological and social consequences, and previousattempts to enhance nurses’ manual handling safety have had limited success. The contextfor nurses’ manual handling experiences has not been comprehensively explored intraditional intervention strategies and this may account, in part, for their limited efficacy(Baptiste et al., 2006; Denis et al., 2008, Hignett and Fray, 2010; Holman, 2006).
Strategies to assist with ‘manual materials handling’, the manual handling of goods, firstemerged in a variety of industrial settings outside of healthcare. Administrators andoccupational health professionals anticipated that the direct application of the genericprinciples gleaned from industry would be sufficient to manage manual handling activitieswithin healthcare settings (Denis et al., 2008). However, this assumption has not beensupported in the light of the persistence of disproportionately high rates of manualhandling injuries internationally amongst nurses in comparison with other occupations(Australian Safety and Compensation Council (ASCC), 2009).
The purpose of this paper was to comprehensively review the literature on both thecontemporary practices of manual handling and the injury prevention interventions adoptedfor use within healthcare settings. This is a narrative review incorporating internationalresearch as the manual handling issues are pertinent to an international audience.
Unique features of the healthcare environment
Normative data for moving and handling objects, such as the threshold recommendationsissued by the National Institute of Occupational Safety and Health (NIOSH) are used toinform many manual handling initiatives, yet the data were generated from controlledlaboratory experiments. While this may be of little consequence for the manual handlingof inanimate objects, it is hardly relevant to the animate, unpredictable and potentiallyuncooperative nature of human loads encountered during the manual handling of patients(Hignett, 2001). The potentially transient nature of a patient’s mobility and cognitive statusis illustrative of the complex manual handling scenarios faced by nurses.
Healthcare involves many and varied manual handling tasks that are integral to patientcare and unique to the industry (Retsas and Pinikahana, 2000). For example, when assistinga patient, nurses may be required to perform potentially hazardous actions such as twisting-turning, lowering, pushing-pulling, prolonged standing, heavy or frequent lifting or bending(Holman, 2006; Larese and Fiorito, 1994). Therefore, manual handling is not limited tolifting and the use of hoists to perform this task. However, manual handling andassociated injury prevention strategies have predominantly focussed on the utilisation ofhoists for lifting and moving patients until recently. Moreover, potentially hazardousmanual handling is not confined to lifting tasks alone, but can arise consequential tonumerous activities related to patient care needs. This was demonstrated clearly in thestudy by Retsas and Pinikahana (2000) whereby a variety of manual handling activities
Kay et al. 227
were identified by survey respondents; those that directly involved patient handling andthose related to other non-direct care activities, such as moving equipment.
Manual handling complexity within healthcare has been exemplified by various studies,including research undertaken in acute care domains. Waters and colleagues (Waters et al.,2011b; Waters et al., 2011d; Waters et al., 2011e) examined high risk tasks present in criticalcare environments. These studies illustrated the diverse nature of manual handling riskexposure in clinical settings, by detailing the numerous actions inherent in the nursing ofpatients who are undergoing surgery (Waters et al., 2011a). For example, the positioning andtransferring of patients demands consideration of the patient’s cognitive status, which maybe impaired by drug effects, in conjunction with the maintenance of medical devices andattachments during manoeuvres (Waters et al., 2007).
Arguably, the unique nature of ‘people-handling’ activities, as opposed to materialshandling, demands closer examination of context-specific issues and more discretelytailored injury prevention strategies (Denis et al., 2008). Many strategies appropriate forthe safe handling of inanimate loads are unsuitable for people-handling tasks. For instance,a common technique to reduce manual handling risk is to physically divide the load intosmaller parts: however this is impossible when moving and handling patients. Otherstrategies, such as the utilisation of mechanical devices are also more problematic forpatient handling contexts (Moody et al., 1996; Smallwood, 2006; Swain et al., 2003).
The complexity of manual handling in healthcare is also illustrated by misunderstandingsthat have emerged relating to manual handling and associated injury prevention strategies.Nelson et al. (2003) identified and addressed several common misconceptions relating tomanual handling. For example, education programmes and the provision of assistive deviceshave been viewed as sufficient stand-alone actions to reduce manual handling risks, despiteevidence to the contrary. In their paper, Nelson et al. highlighted the need for appropriateinfrastructure to support manual handling safety initiatives and the critical appraisal ofevidence-based interventions.
Conceptualising manual handling
Defining manual handling
In Australia, the National Code of Practice for the Prevention of Musculoskeletal Disordersfrom Performing Manual Tasks at Work defines manual tasks as the performance ofphysical actions utilising the musculoskeletal system (ASCC, 2007). Similarly, the Code ofPractice for Manual Handling in Victoria notes a similar range of actions relating to theapplication of force to lift, lower, push, pull, move, carry, hold or restrain in defining manualhandling activities (WorkSafe Victoria, 2000). The European Union’s Manual HandlingDirective, issued in 1990 (Hignett et al., 2007), and the United Kingdom (UK) National1992 Manual Handling Operations Regulations (Health and Safety Executive (HSE), 1992)present similar explanations of manual handling. Definition and guidance relating to manualhandling is less formalised in the United States (USA), and primarily directed by theAmerican Nurses’ Association’s ‘Handle With Care’ campaign (Iakovou, 2008).
Manual handling injuries
Musculoskeletal disorder (MSD) is the term applied to a variety of injuries and conditionsarising from manual handling activities (ASCC, 2007; WorkSafe Victoria, 2000).
228 Journal of Research in Nursing 19(3)
MSDs include sprains, strains or injury to muscles, tendons, ligaments, nerves, bones, joints,intervertebral discs, abdominal hernias and other soft tissue or vascular disorders. Theaetiology of injury development varies from sudden onset after a single, identifiable eventto the accumulation of multiple minor traumas over a prolonged time frame (Waters et al.,2011b; Waters et al., 2011c; WorkSafe Victoria, 2000). It is important to note that the termMSD can refer to reports of pain or discomfort as well as formally diagnosed injuries. Backinjuries have been recognised as the most common type of manual handling injury sustainedby nurses, although MSDs can occur at other sites. The early manual handling literature wasfrequently confined to the investigation of low back pain in nurses and high prevalence rateswere identified in the 1980s (Buckle, 1987; Owen, 1989; Stubbs et al., 1986). This continuedfocus on back injuries was also demonstrated by the 2011 Cochrane Collaboration Review(Verbeek et al., 2011) that examined the efficacy of training in the prevention of back painassociated with materials handling tasks. Pain is generally viewed as a precursor to moresubstantial injuries and the investigation of injuries at other bodily locations, such as theshoulders and upper body, has commenced in recent years (Edlich et al., 2005; Engkvist,2008; Hignett et al., 2003). Reflective of an expanded understanding of manual handlinginjuries in recent years, the scope of injury prevention programmes is no longer confined tolifting activities or back injuries and includes a multiplicity of tasks and a range of potentialinjury sites (ASCC, 2007, Hignett et al., 2007, Iakovou, 2008).
Formal recognition of injuries
A common measure of manual handling injury statistics is the number of claims forcompensation received (Bird, 2009; Charney et al., 2006; Collins et al., 2004; Martinet al., 2009). However, compensation claim approvals are only a subset of manualhandling injuries as claim numbers are consequential to both reporting and approvalprocesses (Menzel, 2008). As such, compensation claim statistics do not recognise allmanual handling injuries which have been incurred and thus underestimate injuryprevalence (Retsas and Pinikahana, 2000). This is particularly significant in the healthcareenvironment where underreporting of injuries and incidents is believed to be much higherthan in other industries, but remains difficult to quantify (Collins and Menzel, 2006; Menzel,2008). The recognition of potential underreporting is important to consider when reviewingthe manual handling literature. Interventions designed to prevent injuries are tailoredtowards prevention of identified injuries such as those reported, and therefore do notnecessarily address issues associated with injuries that are unreported and potentiallyunacknowledged.
Biomechanical model of manual handling
Manual handling activities undertaken by nurses can lead to substantial injuries and thebiomechanical model has been used to explain the development of these injuries (Waterset al., 2011b). The biomechanical model offers an explanation of how manual handlingactivities impact upon human physiology in that the musculoskeletal system generatessubstantial forces in response to manual handling task demands. Similarly, non-liftingactions may result in injury to nurses when a significant biomechanical load is present.In summary, the biomechanical model suggests that manual activities expose humanbeings to high forces generated internally in order to perform the required task.
Kay et al. 229
Biomechanical model and injuries
The biomechanical model postulates that MSDs occur as a consequence of excessive forceson body components or in the presence of repetitive actions preventing sufficient recoverytime between events (Waters et al., 2011b). An early publication by Waters et al. (1993)emphasised the presumptive nature of causal links between manual handling and lower backinjuries.Althoughplausible, the relationshipbetweenmanual handling and injuries is theoreticaland difficult to confirm empirically. A similar point was clearly reiterated in the systematicliterature reviews by van der Molen et al. (2005) and Martimo et al. (2008) whereby the limitsof scientific knowledge were noted in relation to manual handling injuries and interventions.The limited understanding of the nature of forces experienced during manual handling taskswas illustrated by Marras et al. (1999), and later confirmed by their later publication (Marraset al., 2009). The findings by Marras and colleagues in the two aforementioned publicationscontradicted earlier estimates of the forces experienced by nurses during patient care episodes;such forces had previously been underestimated in earlier research and falsely believed to bebelow the threshold for injury development in the majority of individuals. Hence earlyinterventions to prevent injuries had been based on inaccurate data and this may havecontributed to the lack of success of some manual handling strategies.
Foundations for injury prevention strategies
Injury prevention strategies aim to reduce load exposure and thereby reduce the likelihoodof injury (van der Molen et al., 2005). Notably, all strategies for injury prevention assume adirect association between the manual handling of loads and the development of MSDs. Asnoted in the previous paragraph, an understanding of forces and loads associated withmanual handling has changed with advances in scientific knowledge. Table 1 lists keystudies that have investigated the biomechanical nature of manual handling in healthcare,including those related to patient handling assistive devices, and therefore have contributedto the body of knowledge regarding human physiology and biomechanical loads duringmanual handling actions.
Impact of manual handling injuries
The consequences of a single manual handling injury may be considerable and extendbeyond the individual. An injury may impact the injured nurse’s personal andprofessional context as well as current or future healthcare employers (Freshwaterand Cahill, 2010). At a minimum, an injured nurse may experience physical trauma, painand possibly distress. Furthermore, psychological and/or mental health consequences ofinjury and disablement, whether temporary or permanent, may also result from work-related MSDs (Langford, 1997).
A manual handling injury may lead to a reduction in quality of life and cause financialdisadvantage, particularly if the injury endures beyond an acute episode (Retsas andPinikahana, 2000). At an organisational level, the financial burden of manual handlinginjuries includes productivity limitations and direct costs associated with replacement ofstaff and lost time. Vocational choices and employment decisions may be influenced bymanual handling concerns and contribute to a negative perception of nursing as anoccupation (Charney and Schirmer, 2007; Palumbo et al., 2010). Of note, Owen (1989)reported that occupational manual handling injuries led to employment changes for 20%
230 Journal of Research in Nursing 19(3)
of the nurses in their study and an additional 12% of participants expressed an intention toleave their current position.
Literature search strategy
The discussion thus far has provided the contextual background for manual handling inaddition to an overview of the key terms in the manual handling field. The literaturepertaining to manual handling will be presented in the forthcoming sections, following thedelineation of the search strategy used to identify suitable papers for inclusion.
The manual handling literature reviewed in this paper was primarily obtained bysearching electronic databases using keywords and combination keywords as outlined inTable 2. Further searching was performed by the manual inspection of reference lists fromretrieved papers, and was confined to papers available in the English language.
The extensive search performed for this narrative manual handling review highlighted theemphasis on injuries within the literature. The manual handling literature predominantlycomprises two main subsets of articles on injuries: epidemiology studies and evaluations ofinjury prevention programmes (see Figure 1). The majority of interventions reported werecase studies that utilised cross-sectional or pre- and post- designs and lacked control groups.
Manual handling injury epidemiology
Early reviews of manual handling injury rates provided estimates of lifetime low backinjuries in nursing ranging from 35–80% (Buckle, 1987). Subsequent research reported
Table 1. Literature pertinent to biomechanical load reduction
Author(s) Year Country Topic Type of paper
Marras et al. 2010 USA Load exposure and low back
injury
Quantitative
Marras et al. 2009 USA Ceiling and floor based hoists –
spinal forces
Quantitative
Baptiste et al. 2006 USA Friction reducing devices –
clinical use
Quantitative
Lloyd and Baptiste. 2006 USA Evaluation of friction reducing
devices for patient transfers
Quantitative
McGill and Kavcic 2006 Canada Technique for friction reducing
devices
Quantitative
Brace 2005 USA Pushing and pulling – limits Scholarly
Chhokar et al. 2005 Canada Ceiling hoists – 3 year follow up Quantitative
van der Molen et al. 2005 Netherlands Physical work demands –
intervention type;
implementation process
Systematic literature
review
Wright et al. 2005 USA Slings for lifting hoists Scholarly
Trinkoff et al. 2003 USA Hoists and MSD Quantitative
Spiegel et al. 2002 Canada Ceiling hoists – 1 year follow up Quantitative
Marras et al. 1999 USA Dynamic force measurements Quantitative
MSD: musculoskeletal disorder.
Kay et al. 231
Table 2. Databases and results
Databases searched Time period Keywords Results
CINAHL 1999–2011 manual handling OR moving and lifting
patients AND nurs*
87
Academic Search Complete 66
Health Source – Nursing/
Academic Edition
43
MEDLINE 139
CINAHL 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND attitud*
8
Academic Search Complete 2
Health Source – Nursing/
Academic Edition
1
MEDLINE 21
CINAHL 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND belief*
1
Academic Search Complete 1
Health Source – Nursing/
Academic Edition
1
MEDLINE 1
CINAHL 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND
experienc*
11
Academic Search Complete 5
Health Source – Nursing/
Academic Edition
3
MEDLINE 17
Journals@Ovid 1999–2011 manual handling OR moving and lifting
patients AND nurs*
109
Journals@Ovid 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND attitude*
4
Journals@Ovid 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND belief*
2
Journals@Ovid 1999–2011 manual handling OR moving and lifting
patients AND nurs* AND
experienc*
10
ProQuest science journals 1999–2011 Manual handling AND nurs* AND
musculo*
108
ProQuest science journals 1999–2011 Manual handling AND nurs* AND
musculo* AND attitude*
25
ProQuest science journals 1999–2011 Manual handling AND nurs* AND
musculo* AND belief
1
ProQuest science journals 1999–2011 Manual handling AND nurs* AND
musculo*AND experience*
89
Index to Theses 1999–2011 Nurs* AND manual handling 3
ProQuest Dissertations and
Theses
0
Australian Digital Theses 5
Index to Theses 1999–2011 Nurs* AND back pain 10
ProQuest Dissertations and
Theses
0
232 Journal of Research in Nursing 19(3)
similar injury rates across Europe, Scandinavia, Canada, America and the United Kingdom(Hignett, 1996; Hignett et al., 2007; Nelson et al., 2006; Owen et al., 2002; Smedley et al.,2003; Stenger et al., 2007). An Australian paper published in 2008 predicted a lifetime injuryrate of 95.5% based on their cohort of 111 first year graduate nurses (Mitchell et al., 2008).Furthermore, self-reported student nurse injury rates suggested a point prevalence of 26% ina UK cohort (Kneafsey and Haigh, 2007), and a 31% seven-day prevalence in an Australianstudy (Mitchell et al., 2008). Notwithstanding differing injury measurement categories andthe methodological limitations of the above studies, the findings within these internationalstudies revealed the importance of ongoing health issues for nurses. Table 3 lists studies thatincorporated or had MSD prevalence rates as a central feature.
Manual handling interventions
Technique training
The persistently high prevalence of MSDs amongst nurses (Kneafsey and Haigh, 2007,ASCC, 2008) has challenged the utility of traditional injury prevention methods withinthe healthcare industry. Scholars report that the training of nurses in specific liftingtechniques has not adequately prevented manual handling injuries (Hignett et al., 2003;Nelson, 2006; Nelson et al., 2003). On occasion, training may appear to improve manualhandling practices temporarily (Engkvist, 2006), however the impact is short-lived in mostinstances (Bird, 2009; Hignett et al., 2003).
Although training and education are low order risk control strategies, they have beenwidely adopted in the healthcare industry (Nelson and Baptiste, 2006). The conventionalmethod of injury prevention by way of technique training, aspires to modify nurses’ physicaland behavioural characteristics in order to assist nurses to meet the task demands inherent intheir occupation (Allen et al., 2002; Baptiste et al., 2006; Ilmarinen, 2009).
Technique training is typified by a reliance on traditional knowledge and a focus onstrength, technique and compliance by individuals (Hignett and Crumpton, 2007; Nelsonand Baptiste, 2006; Nelson et al., 2008). Whilst many scholars include the use of hoists andother assistive equipment in their recommendations, their papers may reinforce an assumedcentrality of specific techniques to effectively combat injury risk. The development of tools toassess technique performance may likewise infer credibility for technique training.Consequently, attention to the physical environment and contextual factors may beoverlooked by attention to individual performance (Hignett and Fray, 2010). Finally,training content, quality of delivery and suitability have rarely been scrutinised
Figure 1. Representation of themes in the manual handling literature
Kay et al. 233
(Kneafsey and Haigh, 2007; Mitchell et al., 2008) and inconsistency across programmes maybe a confounding variable in evaluation studies (Denis et al., 2008). Intervention evaluationsthat included training or techniques as a key component, are listed in Table 4 below. Theresearch reviewed in this table highlights the continued focus on training programmesdespite limitations for this style of intervention as will be further discussed in the nextsection.
Multidimensional approach to injury prevention
The systematic literature reviews itemised in Table 5 have repeatedly demonstrated theinadequacy of training programmes for injury prevention, particularly when adopted asthe primary or sole intervention (Dawson et al., 2007; Hignett, 2003; Hignett et al., 2003;Martimo et al., 2008; Verbeek et al., 2011). The papers by Clemes et al. (2010), Dawson et al.(2007), Martimo et al. (2008) and Verbeek et al. (2011), all reviewed high quality quantitativestudies and concluded that training and advice had no impact on occupational back pain orback injury. These four systematic reviews suggested that more extensive interventions, those
Table 3. Literature representative of prevalence studies
Author(s) Year Country Topic Type of paper
Yeung and Yuan 2011 Hong Kong Low back pain – aged care assistants Quantitative
ASCC 2009 Aust MSD prevalence – across industries Quantitative
Mitchell 2009 Aust Personal factors for MSD – students Quantitative
ASCC 2008 Aust MSD prevalence in nurses Quantitative
Mitchell 2008 Aust MSD – students and first year graduates Quantitative
Kneafsey and Haigh 2007 UK Student experiences and injury
prevalence
Quantitative
Trinkoff et al. 2006 USA Physical demands and MSD rates Quantitative
Engkvist 2004 Aust Back injury factors- accident process Quantitative
Smith and Leggat 2004 Aust MSD prevalence in student nurses Quantitative
Smedley et al. 2003 UK Neck and shoulder injury – risk factors Quantitative
Trinkoff et al. 2003 USA Prevalence with aids or training Quantitative
Engkvist et al. 2001 Sweden Work conditions of nurses Quantitative
Retsas and
Pinikahana
2000 Aust Scope of nursing demands and
prevalence
Quantitative
Burton et al. 1997 Belgium and
Netherlands
Prevalence of MSD – workload,
psychosocial measures
Quantitative
Langford 1997 Aust Prevalence of nurses’ injuries and
nurses’ experiences
Quantitative
Hignett 1996 UK Review of studies – epidemiology;
interventions; physiological;
techniques
Scholarly
Love 1996 UK Causative factors for lifting injuries Quantitative
Larese and Fiorito 1994 Italy Prevalence of MSDs – work
organisation influences
Quantitative
Owen 1989 USA Prevalence rates Quantitative
Buckle 1987 UK International prevalence rates Quantitative
Aust: Australia; MSD: musculoskeletal disorder.
234 Journal of Research in Nursing 19(3)
of a multidimensional nature, may be more effective for reducing MSD prevalence. Hignett(2003) and Hignett et al. (2003) included quantitative and qualitative studies in their reviewof 63 and 225 papers respectively and also directed attention to multidimensional injuryprevention strategies. Multidimensional interventions have several aspects whichare combined together into one programme, rather than the introduction of a singlefactor solution to manual handling difficulties. The reviews in Table 5 suggest that acombination of elements appears to be more successful in reducing manual handlinginjuries than the provision of a single component programme.
Ergonomics and injury prevention
Multidimensional programmes commonly include the use of ergonomics to addressmanual handling issues. Table 6 cites international literature that incorporated ergonomicapproaches to injury prevention.
Table 4. Literature relevant to training or manual handling techniques
Author(s) Year Country Topic Type of paper
Hughes et al. 2011 USA Prolonged standing in ORs Scholarly
Spera et al. 2011 USA Tissue retraction during surgery Scholarly
Waters et al. 2011 USA Transferring patients in OR Scholarly
Waters et al. 2011 USA Repositioning patients in OR Scholarly
Waters et al. 2011 USA Limb holding during surgery Scholarly
Waters et al. 2011 USA Carrying OR equipment and supplies Scholarly
Waters et al. 2011 USA Moving wheeled OR equipment Scholarly
Hignett and Lu 2010 USA Space to perform tasks Scholarly
Waters et al. 2007 USA Techniques for intensive care settings Scholarly
Johnsson et al. 2006 Sweden Measuring student nurse techniques
after training
Quantitative
Johnsson et al. 2004 Sweden Tool to measure nurses’ technique for
patient transfers
Quantitative
Massy-Westropp
and Rose
2004 Aust Manutention programme – training
focus
Quantitative
Warming et al. 2004 Denmark Combined tool to measure transfer
technique
Quantitative
Kjellberg et al. 2003 Sweden Assessing nurses’ techniques Quantitative
Trinkoff et al. 2003 USA Hoists, transfer sheets, postural
training
Quantitative
Allen et al. 2002 UK Equipment and ‘good’ technique Quantitative
Bewick and Gardner 2000 Aust Training program evaluation Quantitative
Kjellberg et al. 2000 Sweden Assessing individual performance of
techniques (see also Johnnson et al.,
2004)
Quantitative
Kilgariff and Best 1999 Aust Comparison of training programmes Quantitative
Langerstrom et al. 1998 Sweden Evaluation of training programme Mixed method
Best 1997 Aust Manutention training - evaluation Quantitative
Aust: Australia; OR: operating room.
Kay et al. 235
Table 6. Literature depicting ergonomic based interventions
Author(s) Year Country Topic Type of paper
Lim et al. 2011 Canada Ergonomic programme and reinjury
events
Quantitative
Bird 2009 Aust Retrospective case study Quantitative
Martin et al. 2009 Aust Retrospective longitudinal study
VNBIPP
Quantitative
Denis et al. 2008 International Critical review of prevention
programmes – 1980 to 2003
Scholarly review
Nelson et al. 2008 USA Safe handling and patient outcomes Quantitative
Knibbe et al. 2007 Netherlands Ergonomic training programme Quantitative
Stenger et al. 2007 USA Evaluation – ergonomic programme -
equipment, policy
Quantitative
Badii et al. 2006 Canada Programme evaluation- 1 year post:
ergonomic and early return to work
Quantitative
Charney et al. 2006 USA Evaluation of No-lift programme -
equipment
Quantitative
Engkvist 2006 Aust No-lift programme evaluation Quantitative
Collins et al. 2004 USA Ergonomic programme – equipment,
policy
Quantitative
Nelson et al. 2003 USA Myths about nurses’ back injuries Scholarly
Passfield et al. 2003 Aust Retrospective case study Quantitative
(continued)
Table 5. Systematic reviews relevant to multidimensional interventions
Authors Year Number of Articles Time period Topic
Verbeek et al. 2011 9 RCTþ 9 cohort To Feb 2011 Cochrane review -Manual
handling training and assist
devices
Clemes et al. 2010 53 1980–2009 Manual handling training –
healthcare and other
industries
Koppelaar et al. 2009 19 Jan 1988 –Jul 2007 Barriers and facilitators to
patient handling interventions
Martimo et al. 2008 6 RCT and 5 cohort To Nov 2005 Training and equipment for back
pain prevention – nurses and
others
Dawson et al. 2007 8 RCTþ 8 non RCT To Nov 2004 Back injury prevention for
nurses
Hignett 2003 63 includes qualitative 1960–2001 Prevention of MSDs from patient
handling
Hignett et al. 2003 225 1960–2001 Patient handling tasks, equipment
and interventions
RCT: randomised controlled trial; MSD: musculoskeletal disorder.
236 Journal of Research in Nursing 19(3)
The critical review by Denis et al. (2008) warrants examination as this paper promotes theimportance of context in relation to manual handling initiatives due to the complex nature ofmanual handling activities. The authors argue that the classical ergonomic approach ofgeneric problem-solving has become the dominant model for MSD intervention.However, they contend that this informal consensus amongst occupational healthprofessionals has emerged without a detailed understanding of the processes critical to theimplementation of chosen interventions. Denis et al. (2008) provided a novel classification ofergonomic intervention types which incorporated contextual factors in each of the key stepsfor development of intervention strategies, in an attempt to organise the wide variationencountered in the structure and application of ergonomic interventions.
Safety climate and safety culture
Haslam (2002) presented a slightly different emphasis on context relevance and posited thatergonomics frequently includes persuading people to accept practice changes and that suchacceptance is moulded by each individual’s knowledge, beliefs and attitudinal disposition.He asserted that improved outcomes are possible when beliefs and attitudes are recognised,assessed and formally incorporated into ergonomic-based interventions for manual handlingissues. (Table 7 outlines papers related to manual handling issues and safety culture.) Haslam(2002) suggested that the generalised concept of safety culture, which incorporates the notionsof beliefs, attitudes and behaviours, has applicability to the field of manual handling also.Further, he noted in accordance with other scholars, that behavioural modificationprogrammes such as training have limited success when used in isolation.
In an examination of safety climate and culture in work environments, Flin (2007)reviewed factors that might be transferable to healthcare contexts. In this paper, theauthor noted differences in the safety expectations within healthcare when compared toother industries. High reliability organisations (HRO) within high risk industries, such asthe petrochemical or aviation industries, successfully maintain high levels of safety. TheseHROs commonly accept human error as an inevitable feature of task performance, andsafety systems are designed to accommodate this understanding. Flin (2007) argued thathealthcare safety systems are based on a framework expectant of error-free humanperformance as evidenced by a reliance on behaviour modification, in contrast to thepresence of multiple systemic safeguards within HROs. Flin et al. (2000) linkedorganisational culture with successful modification of work practices, and noted theinfluence of attitudes and perceptions inherent in shaping culture, and hence practice.
Table 6. Continued
Author(s) Year Country Topic Type of paper
Trinkoff et al. 2003 USA Hoists, transfer sheets, postural
training
Quantitative
Owen et al. 2002 USA Programme evaluation – 5 years post Quantitative
Hignett 2001 UK Ergonomics and hospital culture Quantitative
Owen 2000 USA Ergonomics - transfers in OR Quantitative
Garg and Owen 1992 USA Ergonomic intervention and forces Quantitative
Aust: Australia; VNBIPP: Victorian nurses’ back injury prevention project.
Kay et al. 237
In particular, workers’ perceptions of management commitment to safety was posited as akey influence on organisational culture. This may partially explain the heterogeneousfindings regarding injury prevention programmes. Interventions that are predominantlytailored to individual compliance with institutional policies may be less robust thansystemic strategies to maintain safe working environments.
Injury prevention strategies - summary
Training nurses in specific lifting techniques to prevent injury has not heralded success andthe uptake of multidimensional manual handling interventions is being encouraged.However the key elements for sustainable solutions to reduce nurses’ manual handlinginjuries have not yet been identified. Consensus is yet to be reached regarding criticalfeatures for manual handling intervention programmes in healthcare and the appropriatemeasures for evaluation of these programmes (Department of Human Services (DHS), 2004;Dawson et al., 2007; Engkvist, 2006; Hignett and Fray, 2010; Hignett et al., 2003). Theunsubstantiated nature of training-based interventions can leave nurses vulnerable to seriousmanual handling injuries. If injuries persist following the implementation of an injuryprevention programme, policy compliance rather than intervention efficacy may be held toaccount for the unanticipated outcome (Kay and Glass, 2011; Cornish and Jones, 2010;Kneafsey and Haigh, 2007). That is, when manual handling injuries occur, instead ofprompting a critical examination of intervention effectiveness, the focus moves to anemphasis on compliance with policy. If this perspective is adopted, then the fault is seento be located within the worker rather than the intervention.
Manual handling from the nurses’ perspectives
A small number of studies have examined the manual handling beliefs, attitudes orexperiences of nurses within quantitative methodology. These studies are listed in Table 8and include three studies related to student nurse populations exclusively, and three papersthat examined attitudes and perceptions regarding manual handling assistive devices.
Table 7. Literature relating to safety culture
Author(s) Year Country Topic Type of paper
Haney and Wright 2007 USA Sustaining ergonomic programmes in
ICU
Scholarly
Flin 2007 UK Safety climate review Scholarly
Hignett et al. 2005 USA Participatory ergonomic programmes Scholarly
Straker et al. 2004 Aust Assessing ergonomic intervention
efficacy
Quantitative
Haslam 2002 UK Ergonomics and health promotion
strategies – stage of change model
Scholarly
Hignett 2001 UK Ergonomics and hospital culture Quantitative
Flin et al. 2000 UK Safety culture Scholarly
Kneafsey 2000 UK Occupational socialisation and handling Scholarly
Westgaard and Winkel 1997 Norway Review of ergonomic interventions Scholarly
Aust: Australia; ICU: intensive care unit.
238 Journal of Research in Nursing 19(3)
The most recent paper by Holman et al. (2010) used postal surveys to explore nurses’perceptions of manual handling in the USA by way of quantitative analysis. Otherscholars have used quantitative methodology to investigate MSDs and the physicalenvironment in which nurses function (Geiger-Brown et al., 2004; Trinkoff et al., 2003).
Table 8. Sample of quantitative literature regarding nurses’ manual handling experiences, belief and
attitudes
Author(s) Year Country Topic Type of paper
Holman et al. 2010 USA Nurses’ perceptions of organisational
factors influencing patient handling
Quantitative
Cornish and Jones 2007 UK Students’ experiences Mixed method
Engkvist 2007 Aust Attitudes to No-Lift intervention and
equipment
Quantitative
Kneafsey and Haigh 2007 UK Students’ experiences Quantitative
Wardell 2007 USA Perceptions about use of equipment Quantitative
Smallwood 2006 UK Students’ beliefs; workplace culture Mixed method
Geiger-Brown et al. 2004 USA Nurses’ MSDs and perceptions of work
environment
Quantitative
Swain et al. 2003 UK Students’ manual handling practices Quantitative
Trinkoff et al. 2003 USA Nurses’ perceptions of physical
demands of nursing and MSD
reporting
Quantitative
Owen 2000 USA Equipment use and attitudes Quantitative
Langford 1997 Aust Survey of nurses’ experiences of
occupational injuries
Quantitative
Aust: Australia; MSD: musculoskeletal disorder.
Table 9. Qualitative literature regarding nurses’ manual handling experiences, belief and attitudes
Author(s) Year Country Topic Type of paper
de Ruiter and Liaschenko 2011 USA Influences on nurses’ assessments of
patient handling needs
Qualitative
Gropelli and Corle 2011 USA Nurses’ and therapists’ experiences of
MSDs
Qualitative
Cornish and Jones 2010 UK Students’ experiences and perceptions Qualitative
de Ruiter 2008 USA Institutional ethnography to understand
patient handling practices
Qualitative
Holman 2006 USA Influences on lifting performance Qualitative
Smallwood 2006 UK Students’ beliefs; workplace culture Mixed method
Green 2002 UK Students’ reflections Qualitative
Green 1996 UK Practices of nurses – observation and
experiences
Qualitative
Moody et al. 1996 UK Attitudes to equipment use Qualitative
Hignett and Richardson 1995 UK Model for influences on patient
handling – nurses’ perceptions
Qualitative
MSD: musculoskeletal disorder.
Kay et al. 239
Table 9 provides details of qualitative studies relating to nurses’ experiences and beliefsregarding occupational manual handling. The earliest paper by Hignett and Richardson(1995) employed a qualitative approach to analyse nurses’ perceptions of manual handlingand ergonomic interventions. In the following year, Moody et al. (1996) interviewed nursesspecifically to investigate their attitudes towards manual handling aids. The studies listed inTable 9 represent the few qualitative manual handling studies undertaken in healthcare asidentified by an extensive search of the literature. These early studies demonstrate the limiteduse of qualitative research to explore manual handling issues and contextual influences, asboth papers examine specific, limited aspects of manual handling. In attempting to uncovermore in-depth data beyond the scope of aids and hoists, additional research has beenundertaken by some scholars. The findings based on qualitative methodologies have thepotential to expand the knowledge of manual handling in healthcare by examiningcontext-specific issues that may not be easily uncovered by other methodologies. Nursesare intimately acquainted with the healthcare environment and research exploring theirexperiences and perceptions may offer new knowledge about the complexities of manualhandling in healthcare settings.
Conclusion
The consideration of context is important in addressing manual handling issues in healthcarebecause the movement and care of patients is different from the handling of inanimateobjects. Industries that successfully manage high risk scenarios tend to incorporate anassumption that human error will occur, and build their systems around this. However,the healthcare industry, characterised by high risk and considerable error, frequentlymanages risk based on strategies that do not accommodate the likelihood of human error.Therefore, when healthcare staff sustain a manual handling injury, organisational responsesto this predicament may include attributing blame to the injured party. In these instances, anassumption of poor compliance with policies dominates rather than the interrogation of theintervention’s efficacy in reducing manual handling risks and thereby preventing injuries.
Systematic literature reviews have repeatedly demonstrated the inadequacy of trainingprogrammes to combat manual handling risks, particularly when adopted as the primary orsole intervention. Over the past eight years, the need for more comprehensive strategies toresolve manual handling issues in healthcare has been consistently identified.
From a review of the available literature there is a dearth of research pertaining to nurses’manual handling experiences. Staff attitudes and beliefs are important components ofworkplace culture and warrant consideration during intervention development andimplementation. Further investigation of nurses’ perspectives on manual handling mayelicit critical features of manual handling issues that have previously been overlooked.
There have been only a few qualitative research studies in the field of manual handling inhealthcare. The application of a qualitative approach promises to bring new opportunitiesfor research to address this important occupational health concern. It is critical to explorenew ways to extend contemporary knowledge, particularly given the ongoing andcomplex nature of manual handling issues in healthcare. Despite years of research and avariety of attempts to reduce the risk of manual handling injury for nurses, includingtechnological developments such as lifting and standing hoists, the problem remainsunresolved.
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Key points for policy, practice and/or research
. Manual handling is more problematic in healthcare than in other industries where onlyinanimate objects are manipulated, as demonstrated by the high prevalence of MSDsamongst nurses.
. Compensation claim statistics underestimate injury prevalence, due to the constraintsinherent in models for, and the reporting of, manual handling injuries.
. Limitations arising from the conceptualisation of manual handling and its managementmay hinder the development of efficacious healthcare interventions to prevent MSDs.
. Training and education are widely adopted strategies for injury prevention inhealthcare, despite systematic literature reviews identifying the need for broad-based, multidimensional interventions.
. Further exploration of nurses’ perspectives may identify previously overlookedcontextual features that are critical to the resolution of manual handling issues.
Declaration of conflicting interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors.
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Kate Kay (RN, Crit Care Nsg Cert, B Sc (Behav), PhD candidate) has post-registrationqualifications in cardiothoracic critical care. Her professional experience includes Qualityand Risk Management, and the roles of Policy Coordinator and Patient Liaison Manager.She recently held the position of Manual Handling Training Coordinator at a large privatehospital in Melbourne, Australia. For several years prior she was a departmental trainer inconjunction with her position as Associate Nurse Unit Manager in a Coronary Care Unit inVictoria, Australia. She is now undertaking a PhD at the Australian Catholic Universityunder the supervision of Professor Nel Glass, Research Professor in Nursing, and SeniorLecturer, Dr Alicia Evans.
Nel Glass (RN, Dip Neuroscience Nsg, BA, MHPEd, PhD, FCN, FRCNA) is a ResearchProfessor in Nursing at the School of Nursing, Midwifery and Paramedicine, Faculty ofHealth Sciences, Australian Catholic University, Melbourne, Victoria, Australia. major. Her
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major research interests include professional and practice development; workplacesatisfaction; hope, optimism and resilience; retention and recruitment; human rights;health and healing and creative expression.
Alicia Evans (RN, Cert Psych Nsg, BN, Grad Cert Higher Ed, MBA, PhD) is a SeniorLecturer in the School of Nursing, Midwifery and Paramedicine at Australian CatholicUniversity, Melbourne. Her programme of research includes psychoanalytic and post-structural approaches to the psychiatric disciplines, healthcare and nursing practice.
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